Client Application


Please provide the following information or you may complete and return the PDF version of this form.

To ensure the quickest turnaround time, be sure to include an electronic copy of the ordering Healthcare Practitioner's license that shows the expiration date or a copy of a voided prescription pad form showing license number.

* Indicates Required Information

General Information

Practitioner Details

Individual Type 1

License

To ensure the quickest possible turnaround time in setting up your account, we ask that you provide an electronic copy of the Ordering Healthcare Practitioner's license that shows the expiration date or a copy of a voided prescription pad form.

Shipping Address

Collection packs and results will be sent to this address

Billing Information

Office Contact

Billing Address

Billing Method Preferences

These preferences may need to be adjusted by our account set-up specialist team based on regulatory requirements for your state.

Convenient and Secure Automated Payment Options for Practitioner Billing

We offer physicians the option to place a credit card on file for laboratory orders marked "Bill Practitioner Account". Physicians who wish to take advantage of our automated credit card payment service must check the "Yes" authorization box below and enter their credit card information.

Automated payments will be charged at the end of each month for any balances on the practitioner's account. Genova Diagnostics will provide a monthly detailed list of credit card charges for reconciliation.

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